Intake and Consent Form

Intake and Consent Form
Owner Information
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Animal Information
Animal's Name
Age, Breed, Male or Female, Intact or Altered
Dog Sport/Activities
Veterinarian/Clinic, Phone Number
What wellness goals are you hoping to achieve?
Does your animal receive any other therapies or modalities? Please list them along with Practitioner Name.
Please list any medications the animal is taking, including supplements.
Describe any injuries, illnesses, procedures or other conditions that your animal has experienced.
My animal is not pregnant, actively bleeding nor has colic.

No contraindications
Consent for care:

I promise to participate fully as a member of my animal’s health care team. I will make sound choices regarding my animal’s health plan based on the information provided by my Veterinarian, PEMF/Cold Laser Professional, and other members of my animal’s health care team. I agree to participate in the self-care program that we select. I promise to inform my animal’s health care team any time I feel my animal’s well-being is threatened or compromised. It is my choice to receive PEMF/Cold Laser for my animal(s), and I give consent for my animal(s) to receive PEMF/Cold Laser Sessions by Callie Cromwell with Pulsed K9. I understand that PEMF/Cold Laser does not diagnose or treat any illness, disease, or any other physical or mental disorder. I also understand PEMF/Cold Laser is a complementary modality and is used to support veterinary care and is not a replacement for any treatment plan.

PEMF/Cold Laser is not a substitute for medical examination or diagnosis. I affirm that I have stated all of my animal’s known medical conditions and shall take it upon myself to keep my PEMF/Cold Laser Professional updated on my animal’s physical and mental health, agreeing there shall be no liability on the PEMF/Cold Laser Professional’s part should I neglect to do so.
Client's Signature

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

Intake and Consent Form

Owner Information

Animal Information